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MyPasTest: MRCS A Online - Jan Exam 201523. Surgical Specialities; Urology (49Qs)
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01. Theme: Urine output
A Acute tubular necrosis
B Acute urine retention
C Blocked catheter
D Dehydration
E Ureteric obstruction.
F Chronic renal failure. Page
1388
Match the most appropriate option from the list above to each clinical situation described below. Each
option may be used once only, more than once or not at all.
Scenario 1
Post-operative emergency AAA repair in the intensive care unit. The patient is haemodynamically stable with good
peripheralcirculation, but his urine output is fluctuating between 1 and 5ml/h.
A - Acute tubular necrosis« CORRECT ANSWER.
Scenario 2
A woman who underwent an open cholecystectomy 24 h ago drops her urine output to 15 ml in 4 h. She is
hypotensive.
B - Acute urine retention« YOUR ANSWER
D - Dehydration« CORRECT ANSWER.
Scenario 3
A 68-year-old man who underwent a bilateral inguinal hernia repair has had no urine output in 36 h. He is not
catheterised.
C - Blocked catheter« YOUR ANSWER
B - Acute urine retention« CORRECT ANSWER.
Scenario 4
A catheterised patient who is in the high-dependency unit with acute pancreatitis had a previously good urine
output. He is well hydrated. He has now been anuric for the last 2 h.
D - Dehydration« YOUR ANSWER
C - Blocked catheter« CORRECT ANSWER.
Acute tubular necrosis is a common cause of acute renal failure in hospital, and in the post-AAA repair
patient, especially in an emergency scenario, this is usually due to systemic hypotension (e.g. due to
haemorrhage).In the surgical patient with low urinary output always ensure there is not an obstruction.
This may be a blocked catheter or, if the patient is not catheterised, acute retention. Acute retention is
common in elderly men. Also check hydration.The minimum urine output acceptable is 0.5 ml/kg/h, but
ideally it should be 1–2 ml/kg/h.
02. Theme: Urology - loin pain
A Urinary calculi
B Pyelonephritis
C Leaking aortic aneurysm
D Pancreatitis
E urinary bladder obstruction
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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
23. Surgical Specialities; Urology (49Qs)
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F Pelvi-ureteric junction obstruction
G Renal cell carcinoma.
For each of the patients described below, select the most likely diagnosis from the list of options above.
Each option may be used once, more than once or not at all. You may believe that more than one
diagnosis is possible but you should choose the ONE most likely diagnosis.
Page
Scenario 1 1389
A 25-year-old female presents to her general practitioner with a 6-month history of recurrent left loin pain. She
says that the pain is worse in the morning. She consumes 3–4 cups of coffee before work.
A - Urinary calculi« YOUR ANSWER
F - Pelvi-ureteric junction obstruction« CORRECT ANSWER.
Loin pain in a young female patient, with the pain worsening after drinking 3–4 cups of coffee, is most
likely to be due to pelvic ureteric obstruction. Symptoms of ureteric obstruction in adults usually occur
after a fluid overload.
Scenario 2
A 22-year-old man presents to the emergency department with left loin pain, pyrexia and tachycardia.
B - Pyelonephritis« CORRECT ANSWER.
One would suspect pyelonephritis in a young male patient with loin pain, pyrexia and tachycardia.
Scenario 3
An 18-year-old man presents to the emergency department with pain in the right iliac fossa and microscopic
haematuria.
C - Leaking aortic aneurysm« YOUR ANSWER
A - Urinary calculi« CORRECT ANSWER.
An 18-year-old man with right iliac fossa pain and microscopic haematuria is most likely to have a urinary
calculus until proven otherwise.
Scenario 4
A 55-year-old lady, with previous history of bilateral reflux, presents to the emergency department with dysuria,
fever and feeling generally unwell.
D - Pancreatitis« YOUR ANSWER
B - Pyelonephritis« CORRECT ANSWER.
The diagnosis would most likely be a pyelonephritis in view of the bilateral reflux, dysuria, malaise and
fever.
Scenario 5
A 75-year-old man presents to the emergency department with hypotension, tachycardia and acute onset of loin
pain, with the pain radiating to the back.
E - urinary bladder obstruction« YOUR ANSWER
C - Leaking aortic aneurysm« CORRECT ANSWER.
A 75-year-old man with hypotension, tachycardia and acute onset of loin/back pain would make one
suspect a diagnosis of leaking or ruptured abdominal aortic aneurysm.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
23. Surgical Specialities; Urology (49Qs)
----------------------------------------------------------------------------------------------------------------------------------
Scenario 6
A 53-year-old man presents to the surgical outpatient clinic with a right-sided loin mass, haematuria and loin pain.
F - Pelvi-ureteric junction obstruction« YOUR ANSWER
G - Renal cell carcinoma« CORRECT ANSWER.
A 53-year-old man with a loin mass, pain and haematuria would point towards a diagnosis of renal cell
carcinoma. Page
1390
03. Theme: Scrotal swellings
A Acute epididymo-orchitis
B Acute haematocoele
C Chronic haematocoele
D Epididymal cyst
E Inguinal hernia
F Orchitis
G Primary hydrocoele
H Secondary hydrocoele
I Testicular seminoma
J Testicular teratoma
K Testicular torsion
L Tuberculous
M Varicocele.
The above are all potential causes of a swelling in the scrotum. For the ensuing clinical scenarios please
pick the most appropriate answer from the list. Each item may be used once, more than once, or not at all.
Scenario 1
A 16-year-old presents to his general practitioner (GP) complaining of a vague, dragging sensation and aching in
the left scrotum. The GP examines him lying flat and cannot identify anything unremarkable within either hemi-
scrotum. On standing, however, there is a soft area of bulging swelling that appears in the left upper scrotum.
A - Acute epididymo-orchitis « YOUR ANSWER
M - Varicocele« CORRECT ANSWER.
M – Varicocele:
This is a condition of varicosities of the pampiniform plexus of veins (ie varicose veins of the spermatic
cord) and is present in 15–25% of all men. They usually manifest first in adolescence and are more
common on the left. This is explained by the venous drainage of the left testicular vein into the left renal
vein at right angles (the right testicular vein drains obliquely into the inferior vena cava). Absent or
incompetent valves at this junction with the left renal vein lead to back pressure, and the formation of the
varicocele.
On examination at this early stage and with the patient standing the varicocele is said to feel like a ‘bag of
worms’ (Grade 2); it cannot be felt supine at this stage as the veins are empty. Usually varicoceles are
managed conservatively (close-fitting underwear, reassurance, analgesia for testicular ache); however,
troublesome varicosities can be treated by radiological embolisation, or by surgical ligation of the
testicular veins in the inguinal canal.
Scenario 2
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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
23. Surgical Specialities; Urology (49Qs)
----------------------------------------------------------------------------------------------------------------------------------
A 13-year-old boy presents to Casualty in the early hours of the morning complaining of unbearable pain in his left
scrotum. The onset was sudden, woke him from sleep and caused him to vomit.
B - Acute haematocoele « YOUR ANSWER
K - Testicular torsion« CORRECT ANSWER.
K – Testicular torsion:
The classical age, history and clinical presentation in this scenario clearly points to testicular torsion. The Page
commonest age for torsion is between 10 and 15 years and the problem is very uncommon over the age 1391
of 25 years. The majority of torsions occur spontaneously, often in the early hours of the morning;
however, some follow minor trauma (eg blow to the scrotum during sport or while mounting a bicycle). In
young sexually active men it may be difficult to distinguish between an acute epididymo-orchitis and
testicular torsion. Surgical exploration is compulsory.
Scenario 3
A 47-year-old man presents to the urology outpatient clinic with a 3–4-year history of a slowly enlarging, non-
tender swelling in his right scrotum. On examination you note a multilocular 2-cm swelling located at the upper,
posterior pole of the right testis. It is fluctuant, transmits a fluid thrill and transilluminates. The cord is easily
palpated above the bulge.
C - Chronic haematocoele « YOUR ANSWER
D - Epididymal cyst « CORRECT ANSWER.
D – Epididymal cyst:
Epididymal cysts are fluid-filled swellings connected to the epididymis and are thought to be derived from
the collecting tubules of the epididymis. Most occur in men over the age of 40 years who complain of a
slowly enlarging, non-tender bulge in the scrotum. Clinically they are as described in the scenario above.
The differential diagnosis is that of a hydrocoele, but the epididymal cyst can easily be distinguished
because of its position above and behind the superior pole of the testis. The fluid of a hydrocoele
surrounds the testis and usually makes the testis impalpable.
Scenario 4
A 27-year-old man attends The Emergency Department complaining of bilateral testicular pain and swelling. He
gives a 5-day history of fever and malaise and tells you that he had some bilateral jaw swelling and pain that
appears to be settling now. On examination he has a temperature of 38.9°C; his testes are swollen, tender to
palpation and feel somewhat soft.
D - Epididymal cyst « YOUR ANSWER
F - Orchitis« CORRECT ANSWER.
F – Orchitis:
This man’s history of fever, malaise and parotitis indicates infection with the mumps virus (a systemic
paramyxovirus). Orchitis occurs in up to 20% of post-pubertal men that contract the virus, commencing
4–6 days after the onset of the parotid gland swelling and lasting 7–10 days. Diagnosis is confirmed by
the rising titre of anti-mumps antibody. Treatment is supportive (bed rest, analgesia and scrotal support).
Mumps orchitis can be complicated by testicular atrophy. If the orchitis is bilateral fertility may be
impaired.
04. Theme: Treatment options for renal/ureteric calculi
A Percutaneous nephrolithotomy
B Conservative management
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
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